Reasons why women request caesarean sections need to be explored more by clinicians

Clinicians need to explore the reasons behind why women request a caesarean section rather than counsel women about the risks says a new review published today (17 October) in The Obstetrician & Gynaecologist (TOG).

Caesarean section on maternal request (CSMR) is carried out in the absence of maternal or fetal indications. One of the main psychological causes is tokophobia, an intense fear of childbirth affecting between six to ten percent of women.

In addition, women who have had previous vaginal delivery may request caesarean section because of adverse experiences during labour known as secondary tokophobia.

The authors of the review state that rather than counselling women requesting caesarean section about the risks, a better approach would be to explore the reasons for the request.

For women with tokophobia, frequent, regular psychotherapy by trained personnel to address why they are requesting a caesarean section is recommended by the review.

Authors state health workers need to have detailed discussions with women requesting a caesarean section about the unpredictability of events surrounding labour, the lack of control and the need for a flexible birth plan. Local maternity unit statistics for intervention rates should also be provided to women.

Furthermore, women who have experienced a traumatic birth should have access to support in the postnatal period.

Other factors such as future childbearing plans and obesity should be discussed. For example, women who want more than one child should be informed of the benefits of vaginal delivery and the complications associated with repeated caesarean section. Obesity can increase the risk of operative vaginal delivery, emergency caesarean section and pelvic floor damage.

The review also considers the justification for CSMR and the ethical dilemma clinicians face. It highlights the importance of individual rights and the rights of society and the difficulty of balancing the two.

The risks and benefits of caesarean section are also explored including how anal incontinence, urinary incontinence and pelvic organ prolapse are all possible consequences of vaginal delivery.

Dr Vivek Nama, Clinical Research Fellow, Department of Obstetrics and Gynaecology, St George’s University of London and co-author of the paper said:

“The current approach is to discuss the risks and benefits of caesarean section, however, counselling should move away from discussing the risks to addressing the reasons for a request.

“Women with a fear of childbirth have serious concerns about birth and related issues and exploring their fears, together with counselling, has been shown to alleviate them.”

TOG’s Editor –in-Chief, Jason Waugh said:

“Tokophobia can affect women who have had a previous traumatic birth experience and it is important that women receive high quality postnatal care and are given all the information needed for making a decision about subsequent pregnancies.”